A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?

Explanation

Choice A Reason:

Assessing the newborn's latch while breastfeeding the newborn is correct. Sore nipples are a common issue for breastfeeding mothers and are often caused by an improper latch. Assessing the newborn's latch while breastfeeding is essential to identify any issues such as shallow latch, improper positioning, or tongue tie that may be contributing to the soreness. Correcting the latch can help alleviate nipple pain and prevent further damage to the nipples.

Choice B Reason:

Offering supplemental formula between the newborn's feedings is incorrect. Offering supplemental formula is not indicated for sore nipples unless there are other indications such as insufficient breast milk supply or poor weight gain in the newborn. Supplementing with formula can interfere with establishing and maintaining breastfeeding and may exacerbate nipple soreness by reducing the frequency of breastfeeding, which can lead to engorgement and decreased milk production.

Choice C Reason:

Instructing the client to wait 4 hr between daytime feedings is incorrect. Waiting 4 hours between feedings is not appropriate for a breastfeeding newborn, especially in the early postpartum period. Newborns typically need to feed frequently, every 2-3 hours or more, to establish milk supply, gain weight, and meet their nutritional needs. Delaying feedings can lead to hunger, dehydration, and decreased milk production.

Choice D Reason:

Having the client limit the length of breastfeeding to 5 min per breast is incorrect. Limiting breastfeeding sessions to 5 minutes per breast is not recommended, especially for a breastfeeding newborn. Newborns need to feed for an adequate duration on each breast to ensure they receive enough milk and stimulate milk production. Restricting feeding time can lead to insufficient milk intake, poor weight gain, and decreased milk supply.

Explanation

Choice A Reason:

Applying an ice pack to the incision site may provide comfort but does not address the underlying cause of the vaginal bleeding. Additionally, applying cold therapy to the incision site may not be recommended immediately after surgery as it can interfere with wound healing.

Choice B Reason:

Administering 500 mL lactated Ringer's IV bolus is inappropriate. While administering IV fluids may be indicated in the management of postpartum hemorrhage to support intravascular volume, it should be based on a comprehensive assessment of the client's condition and vital signs, including blood pressure and heart rate. Administering fluids without a thorough evaluation may not address the underlying cause of the bleeding and could potentially exacerbate the situation.

Choice C Reason:

Evaluating urinary output is inappropriate. Steady vaginal bleeding that persists despite fundal massage after a cesarean birth may indicate postpartum hemorrhage (PPH). PPH is a serious complication that requires prompt assessment and intervention. One of the primary causes of PPH is uterine atony, which is when the uterus fails to contract adequately after delivery.

Choice D Reason:

Replacing the surgical dressing is inappropriate. While maintaining a clean and dry surgical dressing is important for wound care, it does not address the underlying cause of the vaginal bleeding. In this situation, the priority is to assess and manage the potential causes of postpartum hemorrhage, such as uterine atony and urinary retention.